Violence in Psychiatry

9781316135839

Focusing on violence from assessment, through underlying neurobiology, to treatment and other recommendations for practice, this book will be of interest to forensic psychiatrists, general adult psychiatrists, psychiatric residents, psychologists, psychiatric social workers and rehabilitation therapists.

This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press.

Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.

Introduction

Evidence has accumulated that shows that patients with a mental illness in a hospital setting have higher rates of violence in comparison to people with mental illness living in the community [1–3]. Investigations into patient violence in psychiatric hospitals have typically examined variables such as sex, age, ethnicity, and diagnosis. These investigations have typically found higher prevalence of violence among inpatients who are female [4–7], younger [8–10], and of ethnic minority status [11,12]. However, these findings have not been universal across all studies, as noted in the review by Bowers et al. [13] Their review found that of the 26 studies of psychiatric inpatients that specifically investigated the roles of age and aggression, 13 reported no significant relationship and 13 reported that aggressive patients were significantly younger.

Likewise, with regard to diagnosis, their review again found discrepancies; across 19 studies, nine reported no significant differences in diagnosis between the aggressor and non-aggressor groups, and only one study directly addressed the issue of personality disorder among aggressive and non-aggressive groups [9]. The presence and number of contradictory findings raises questions regarding methodological issues, such as the setting of the study (and subsequent generalizability to other settings), along with issues of statistical power related to the sample size of the study, which may have limited the ability of the investigators to find significance when the impact of a variable was small.

In the decade or more since many of these studies were conducted, there have been significant changes in the state psychiatric hospital system; these include a simultaneous reduction in hospital beds with an increase in the demand for beds by the criminal court system (i.e., forensic patients) [6,14]. Nationwide, as of 2012, expenditures by state psychiatric hospitals for forensic patients had grown to 36% of the total budget, with an additional 4.7% of expenditures dedicated for persons committed under sex offender commitment statutes. While several states now have a forensic population over 50% of the total inpatient population, perhaps nowhere has this impact been felt more than in the California State Hospital system, where shifts over the past decade have resulted in criminal-related, forensic inpatients comprising over 92% of the hospitalized patients.

The increasing number of forensic patients admitted to state hospitals creates a number of concerns, chief among these the concern of risk for violence. Because commitment to a state hospital in California requires an assessment of whether the patient can be safely treated in the community as an alternative to hospitalization, a patient can only be committed if the court finds that person too dangerous to treat in the community. Since the only distinguishing feature between those treated as outpatients or committed to a state hospital is that of dangerousness, in essence patients are hospitalized by courts primarily due to the issue of dangerousness and secondarily due to mental illness. Also considering the requirements of the commitment criteria in California, as the patients committed by the courts are presumed to be dangerous, they cannot be discharged solely by the treatment team’s recommendation; the court must evaluate any treatment team discharge recommendation and can choose to follow or not follow any such recommendation based on the relevant legal issue(s) brought up at the hearing or trial. This potentially can increase the length of stay of these patients, beyond what would reasonably be expected for simple treatment of their mental illness needs. In view of previous research findings that patients who were more violent in the community are more likely to be violent while hospitalized, and those patients diagnosed with schizophrenia with recent violence or law enforcement contact have increased violence risk, there are concerns that violence by forensic patients in state hospitals may be both quantitatively and qualitatively different from violence in other psychiatric facilities that do not treat forensic patients [2,4]. Owing to these issues, and a need to develop effective methodologies to decrease violence, we decided to enumerate both the prevalence of violent assaults, as well as investigate details of the assaults that may warrant further evaluation.

Previous studies that examined prevalence of inpatient violence in psychiatric facilities typically followed one of several common methodologies. Studies conducted before 2000 routinely used questionnaire-type surveys administered to staff, asking about previous violence – a technique methodologically subject to under-reporting [15,16]. Another methodology was to conduct a one-year “look-back” at the violence committed by all patients resident in the hospital, which could systematically overlook patients resident during any part of the year but discharged prior to the study initiation [6,16]. In one such study, it is estimated that potentially up to 25% of all patients resident at any point during the year were not included [6]. More recent studies have commonly followed inpatients for a prescribed length of time and had nursing staff fill out standardized aggression surveys immediately after aggressive/violent events [7]. An issue for some of these studies is that nursing time resources are needed, if aggression ratings forms are not a routine part of nursing duties, resulting in a more limited duration for the study period.

The present study endeavored to overcome these limitations encountered by past investigations by using a computerized violent incident reporting system that is routinely used by staff to record the occurrence of every violent incident. Use of other available patient databases enabled us to cross-reference patient information with the violent incident data, and determine who was and was not violent. Additionally, the use of these databases allowed us to track and record every patient and every violent incident for three years, allowing a sufficient time period to ensure a representative portrayal of violent incidents over time. To the best of our knowledge, this is the single largest study on violent assaults in a state psychiatric hospital system.

Colin A. HodgkinsonLaboratory of Neurogenetics, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA

Brian J. HoloydaDepartment of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Sacramento, California, USA

Matthew J. HoptmanSchizophrenia Research Division, Nathan Kline Institute for Psychiatric Research, Orangeburg, Department of Psychiatry, New York, USA, and University School of Medicine, and Department of Psychology, City University of New York, New York, USA

K. Luan PhanDepartment of Psychiatry, University of Illinois College of Medicine, Mental Health Service Line, Jesse Brown Veterans Administration Medical Center, and Departments of Psychology, and Anatomy and Cell Biology, University of Illinois at Chicago, Chicago, Illinois, USA

Barbara E. McDermottDepartment of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Sacramento, California, USA

Jonathan M. MeyerDepartment of Psychiatry, University of California–San Diego, San Diego, California Department of State Hospitals, and Patton State Hospital, California, USA

John MonahanSchool of Law, University of Virginia, Charlottesville, Virginia, USA

Matteo PardiniDepartment of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, and Magnetic Resonance Research Centre on Nervous System Diseases, University of Genoa, Genoa, Italy

Katalin A. SzaboDepartment of Psychiatry, San Mateo Health System, San Mateo, and Behavioral Health and Recovery Services, San Mateo, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA

John TullyDepartment of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

Stephen C. P. WongDepartment of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, School of Medicine, University of Nottingham, Nottingham, UK, and Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Australia